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® Waste Tire St.. .ay & Inspection Repo _ Inspection Report Number <br /> Blll State California I 1 - 1127893 <br /> CIWMBB 161( e ) Survey Form - Page 1 <br /> California Integrated WasttManage <br /> Waste Management Board <br /> Part A- Survey- BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details - - - <br /> TPID- � Inspection Type (Fill one) <br /> Site Suffix: ` 4-1 U 'S C1 C It Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �� �t• l CC If <br /> 0 CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address <br /> C <br /> Inspection Date <br /> I <br /> ) / <br /> ( A _ Lr 1 <br /> Q5`7 7 6 Time In Time Out <br /> Business Rep Title ®AM ® AM <br /> C� �Z Q PM r 5- 6 O PM <br /> - Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) <br /> ® Active Q Passenger ® Generator � ® Outdoor <br /> O O Closed Q Altered <br /> GPS Latitude O Hauler Q Indoor <br /> O O Inactive Truck <br /> Longitude - O Planned Q OTR End-Use Container <br /> Business Type (Fill all that apply) <br /> O New Tire Dealer Q Auto Repair (a Trucking Fleet Q Government Q Retreader Q Dismantler O Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V q I HAULING AND MANIFEST REQUIREMENTS Notice Of Violation Q Extension <br /> O O PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> O O PRC§42953-Contracts with Registered Waste Tire Haulers. i Compliance Deadline <br /> O O PRC§42956-Registration/Decal in Vehicle <br /> OO 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date M / FR / M <br /> Q Q . 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> (Required for NOV or EXE <br /> O O 14 CCR§ 18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days <br /> � <br /> O O 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> O O 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred I CIWMB Enforcement <br /> O O 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> O O 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance - No Violations <br /> 0 O Other: § ------ <br /> Comments <br /> --- <br /> Inspection Form Included: QI — <br /> Comments Included: - __ _ __ <br /> si Rep's ignature Phone Number n e or' I ature Phone Number <br /> 6208 <br /> INSTRUCTIONS ON BACK Correct: Incorrect -V 1� <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA <br />